Mcq Companionto Applied Radiological Anatomy3 Haxap

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Mcq Companionto Applied Radiological Anatomy3 Haxap

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  2. 2. MCQ Companion to Applied Radiological Anatomy This helpful revision aid will be of great practical benefit to all trainees in radiology, including those studying the new modular curriculum for Fellowship of the Royal College of Radiologists Part 2A examination. The carefully structured questions and answers enable the trainees to undertake a systematic assessment of their knowledge, as well as highlighting areas where additional revision is required. This publication has been designed to complement its highly illustrated companion volume Applied Radiological Anatomy (by Butler, Mitchell & Ellis), which itself serves as a comprehensive overview of anatomy as illustrated by the full range of modern radiological procedures. Both books can be used independently of one another; however, it is anticipated that the trainee will gain maximum benefit from using the two books together. Although allied closely to the curriculum for the new radiology exam, the choice of questions will be relevant and useful for radiology trainees world-wide. Arockia Doss is Specialist Registrar in the Department of Radiology of the Royal Hallamshire Hospital at the Sheffield Teaching Hospitals NHS Trust, UK Matthew J. Bull is Consultant Radiologist and Program Director of the North Trent Radiology Training Scheme of the Sheffield Teaching Hospitals NHS Trust at the Northern General Hospital in Sheffield, UK Alan Sprigg is Consultant Radiologist in X-ray and Imaging at the Sheffield Children’s Hospital at the Sheffield Teaching Hospitals NHS Trust, UK Paul D. Griffiths is Professor of Radiology in the Section of Academic Radiology of the Department of Radiology at the Royal Hallamshire Hospital at the Sheffield Teaching Hospitals NHS Trust, UK
  3. 3. MCQ Companion to Applied Radiological Anatomy Arockia Doss, Matthew J. Bull Alan Sprigg and Paul D. Griffiths Sheffield Teaching Hospitals NHS Trust, UK
  4. 4.    Cambridge, New York, Melbourne, Madrid, Cape Town, Singapore, São Paulo Cambridge University Press The Edinburgh Building, Cambridge  , United Kingdom Published in the United States by Cambridge University Press, New York www.cambridge.org Information on this title: www.cambridge.org/9780521521536 © A. Doss, M.J. Bull, A. Sprigg & P.D. Griffiths 2003 This book is in copyright. Subject to statutory exception and to the provision of relevant collective licensing agreements, no reproduction of any part may take place without the written permission of Cambridge University Press. First published in print format 2003 ISBN-13 978-0-511-06553-8 eBook (NetLibrary) ISBN-10 0-511-06553-1 eBook (NetLibrary) ISBN-13 978-0-521-52153-6 paperback ISBN-10 0-521-52153-X paperback Cambridge University Press has no responsibility for the persistence or accuracy of s for external or third-party internet websites referred to in this book, and does not guarantee that any content on such websites is, or will remain, accurate or appropriate.
  5. 5. To my Dad and wife Josephin who always gave me the best AD To Amanda, Charlotte, Emily and Lydia MJB
  6. 6. Contents Foreword page ix Preface and Acknowledgements xi Module 1 Chest and cardiovascular 2 A. Doss and M.J. Bull Limb vasculature and lymphatic system* 20 A. Doss and M.J. Bull *From Applied Radiological Anatomy: ‘The limb vasculature and the lymphatic system’ Module 2 Musculoskeletal and soft tissue (including trauma) 30 A. Doss and M.J. Bull Module 3 Gastro-intestinal (including hepatobiliary) 48 A. Doss and M.J. Bull Module 4 Genito-urinary and adrenal (renal tract and retroperitoneum)* 80 A. Doss and M.J. Bull Pelvis* 90 A. Doss and M.J. Bull Obstetric anatomy 100 A. Doss and A. Sprigg The breast 104 A. Doss and M.J. Bull *From Applied Radiological Anatomy: ‘The renal tract and retroperitoneum’ and ‘The pelvis ’ vii
  7. 7. viii Contents Module 5 Paediatric anatomy 112 A. Doss and A. Sprigg Module 6 Neuroradiology 122 A. Doss and P.D. Griffiths Extracranial head and neck (including eyes, ENT and dental)* 162 A. Doss and M.J. Bull The vertebral column* 174 A. Doss and M.J. Bull *From Applied Radiological Anatomy: ‘Extracranial head and neck’ and ‘The vertebral and spinal column’ Index 186
  8. 8. Foreword It is a pleasure to write a Foreword to this book of MCQs. Sometimes an ‘accompanying volume’ is a poor relation of the original; not this one – it made me thirst to go to the excellent original to check and recheck my (rusty) facts! It is also pleasing to see an MCQ book entirely devoted to radiological anatomy. Many medical schools are currently reducing the content of their anatomy (morphology, architecture, etc.) courses, given perceived overloading of the curriculum. Thus future radiological trainees may have less background anatomical knowledge than their predecessors. Radiology depends entirely on being able to recognise normal anatomy, anatomical variants thereof and abnormal structures. Indeed, detailed knowledge of anatomy and applied techniques is usually the deciding characteristic among radiologists and clinicians with an interest in imaging. It behoves all radiologists to learn anatomy in depth and to maintain and develop that knowledge throughout their professional career. This book also serves as a reminder to examination candidates (and examiners) that anatomical questions are still very much in vogue within the new Royal College of Radiologists’ examination scheme. This book jumps ahead so that the questions are grouped together in system-based modules: a forerunner of things to come. Setting MCQs is no easy task. The authors have done a good job to make them relevant and realistic for examination purposes. Of course, there will be one or two minor quibbles when the book is reviewed and most statements including ‘may’ are true! However, this is not the point. This is a revision (or in some cases a vision) for those working to attain a certain standard of radiological anatomical knowledge. To this end, this slim volume will be an enormous help and even makes for an amusing brain exercise for more senior citizens. I congratulate the authors and hope that the book gains the success it deserves. Adrian K. Dixon July 2002 ix
  9. 9. Preface One of the best ways to prepare well for an MCQ exam is to make up MCQs whilst reading a text. This book is the result of such an effort for the Fellowship of the Royal College of Radiologists (FRCR) 1 exam with the textbook Applied Radiological Anatomy. The Royal College of Radiologists recently introduced the modular exam for the FRCR 2A. The radiological anatomy, techniques and physics will contribute about 15–20% of all the MCQs. The purpose of this work is to present questions on radiological anatomy for the six modules of the FRCR 2A. Therefore, the book is presented as six modules, each representing a module for the FRCR 2A. The modules should be read in conjunction with chapters in the textbook Applied Radiological Anatomy. The questions with the relevant answers are on opposite pages which makes easy reading. Some questions are based on pathology and some are related to general radiological technique from day-to-day practice. It is hoped that this will be stimulating to the trainee and help with better understanding in acquiring the general skills of performing and reporting radiological examinations. We have not included a separate module on surface anatomy. However, questions on relevant surface anatomy are included in the various modules. Some of the chapters from Applied Radiological Anatomy have been included in a related module. For example, the chapter on renal tract and retroperitoneum and pelvis has been included in Module 4. It is hoped that this book will provide radiology trainees with a focused approach to learning MCQs from different anatomical locations and prepare them well for the modules of the FRCR 2A. AD, MJB, AS, PDG Sheffield, UK January 2002 xi
  10. 10. Acknowledgements AD is indebted to Drs M. J. Bull, A. Sprigg and Professor P D. Griffiths, as . this book would not have been possible without them. AD is also grateful to Drs Michael C. Collins, Robert J. Peck, Richard Nakielny, Christine Davies, Tony Blakeborough, and all Consultant Radiologists of the Sheffield Teaching Hospitals NHS Trust, Sheffield, UK, whose teachings have been included in the text. AD would also like to thank Peter Silver in the publications department for his support and enthusiasm. We thank all our families for their patience during the preparation of this book. We also thank Liz and Jane at the Northern General Hospital, Sheffield, for the preparation of the manuscript.
  11. 11. Module 1
  12. 12. Chest and cardiovascular A. Doss and M. J. Bull 1. Regarding the imaging modalities of the chest: (a) High resolution computed tomography (HRCT) uses a slice thickness of 4–6 mm to identify mass lesions in the lung. (b) Spiral CT ensures that no portion of the chest is missed due to variable inspiratory effort. (c) MRI shows excellent detail of the lung anatomy. (d) Bronchography is the technique of choice to visualize the bronchial tree (e) CT pulmonary angiography (CTPA) is performed using catheters placed in a femoral vein. 2. Regarding the development of the lung: (a) The tracheobronchial groove appears on the ventral aspect of the caudal end of the pharynx. (b) The primary bronchial buds develop from the tracheobronchial diverticulum. (c) The epithelium lining the alveoli is the same before and after birth. (d) A persistent tracheo-oesophageal fistula (TOF) is commonly associated with an atresia of the duodenum. (e) Uni-lateral pulmonary hypoplasia is usually due to a congenital diaphragmatic hernia. 3. Regarding the blood supply to the chest wall: (a) The posterior intercostal arteries supply the 11 intercostal spaces. (b) The internal thoracic artery arises from the subclavian artery and supplies the upper six intercostal spaces. (c) The neurovascular bundle passes around the chest wall in the subcostal groove deep to the internal intercostal muscle. 2
  13. 13. Chest and cardiovascular ANSWERS 1. (a) False – HRCT uses 1–2 mm slice thickness and a high resolution computer algorithm to show fine detail of the lung parenchyma, pleura and tracheobronchial tree. It is not used to delineate masses in the lung. (b) True (c) False – currently MRI is a poor technique for showing lung detail. It allows visualisation of the chest wall, heart, mediastinal and hilar structures. (d) False – this invasive technique has largely been superseded by HRCT. (e) False – CTPA is performed to diagnose major pulmonary emboli using a cannula placed in any peripheral vein and is relatively non-invasive compared to conventional pulmonary angiography. 2. (a) True (b) True – the bronchial buds differentiate into bronchi in each lung. (c) False – during embryonic life the alveoli is lined by cuboidal epithelium that lines the rest of the respiratory tract. When respiration commences at birth the transfer to the flattened pavement epithelium of the alveoli is accomplished. (d) False – TOF indicates the close developmental relationship between the foregut and the respiratory passages. It is usually associated with an atresia of the oesophagus and the fistula is situated below the atretic segment. (e) True 3. (a) False – there are usually nine pairs of posterior arteries from the postero-lateral margin of the thoracic aorta, distributed to the lower nine intercostal spaces. The first and second spaces are supplied by the superior intercostal artery, branches of the costocervical trunk from the subclavian artery. (b) True (c) True 3
  14. 14. 4 Module 1: Chest and cardiovascular (d) The intercostal spaces are drained by two anterior veins and a single posterior intercostal vein. (e) The posterior intercostal vein drains into the internal thoracic vein. 4. Regarding the azygos venous system: (a) The azygos vein at the level of the fourth thoracic vertebra arches over the root of the right lung to end in the superior vena cava (SVC). (b) About 10% of the population have an azygos lobe. (c) The thoracic duct and aorta are to the right of the azygos vein. (d) The second, third and fourth intercostal spaces on the right, drain via the right superior intercostal vein into the azygos vein. (e) In congenital absence of IVC the azygos vein enlarges. 5. Regarding the hemiazygos and accessory hemiazygos venous systems: (a) The hemiazygos vein at the level of the fourth thoracic vertebra crosses the vertebral column behind the aorta, oesophagus and thoracic duct. (b) The ascending lumbar veins and the lower three posterior intercostal veins are the tributaries of the hemiazygos vein. (c) The accessory hemiazygos vein receives the fourth to the eighth intercostal veins on the left. (d) The accessory hemiazygos vein may drain into the left brachiocephalic vein. (e) The first posterior intercostal vein may drain into the corresponding vertebral vein. 6. Regarding the airways: (a) In adults the right main-stem bronchus is steeper than the left. (b) The left main bronchus is about twice as long as the right. (c) The bronchioles contain cartilage. (d) Gas exchange takes place in the terminal bronchioles and acini. (e) The bronchopulmonary segments are based on the pulmonary arterial system.
  15. 15. 5 Module 1: Chest and cardiovascular (d) True (e) False – posterior intercostal veins drain into the brachiocephalic vein and azygos system. The anterior veins drain into the musculo-phrenic and internal thoracic veins. 4. (a) True (b) False – in 1% of the population, the azygos vein traverses the lung before entering the SVC resulting in the azygos fissure. The azygos ‘ lobe’ is not a true segment. (c) False – they are to its left. (d) True – hemiazygos, accessory hemiazygos, oesophageal, mediastinal, pericardial and right bronchial veins drain into the azygos system. (e) True – in the azygous continuation of the IVC, the azygos is a large structure, but otherwise the anatomy is unaltered. This may be confused with a mediastinal mass. 5. (a) False – at the level of T8. (b) True – and subcostal veins of the left side, some mediastinal and oesophageal veins. (c) True – sometimes the bronchial veins. (d) True – through the left superior intercostal vein. It may join the hemiazygos and/or drain into the azygos vein at the level of T7. (e) True – or the corresponding brachiocephalic vein. 6. (a) True (b) True (c) False – after 6 to 20 divisions the segmental bronchi no longer contain cartilage in their walls and become bronchioles. (d) False – the terminal bronchiole is the last of the purely conducting airways, beyond which are the gas-exchange units of the lung – the acini. (e) False – based on the divisions of the bronchi.
  16. 16. 6 Module 1: Chest and cardiovascular 7. Regarding the secondary pulmonary lobule: (a) It consists of approximately ten acini. (b) The lobular vein follows the branches of the bronchioles. (c) Lymph drainage is both interlobular and central along the arteries. (d) Lobules are best demonstrated nearer to the hilum of the lung on CT. (e) The interlobular septa are seen usually on conventional CT. 8. Regarding the pulmonary blood vessels: (a) The bronchovascular bundle of the secondary pulmonary lobule is demonstrated as a rounded density about 1 cm away from the pleural border on axial CT. (b) The inferior pulmonary veins draining the lower lobes are more vertical than the lower lobe arteries. (c) The upper lobe veins lie lateral to the arteries. (d) In a frontal chest radiograph the artery and bronchus of the anterior segment of the upper lobes are frequently seen end-on. (e) The left pulmonary artery passes anterior to the left main bronchus. 9. Regarding the pleura: (a) The parietal pleura is continuous with the visceral pleura at the hilum. (b) On a PA radiograph the pleura is seen in the costophrenic sulcus. (c) The parietal pleura is supplied by the pulmonary circulation. (d) The fissures usually contain a layer of parietal and visceral pleura. (e) The intercostal stripe is seen on axial CT as a linear opacity of soft tissue density at the intercostal space. 10. Regarding the fissures of the lung: (a) Complete fissures may be crossed by small bronchovascular structures seen on HRCT. (b) The oblique fissure separates the upper and lower lobes from the middle lobe on the right.
  17. 17. 7 Module 1: Chest and cardiovascular 7. (a) True – acini are 8–20 mm in diameter and consists of respiratory bronchioles, alveolar ducts and alveoli. (b) False – the lobular artery follows the branches of the bronchioles. Peripheral veins drain the lobule and run along the interlobular septum. (c) True (d) False – lobules are surrounded by connective tissue septa which contain veins and lymphatic vessels, in the lung periphery. Therefore they are best demonstrated in the periphery of the lung. (e) False – they can just be appreciated on HRCT. 8. (a) True (b) False – the opposite is true. (c) True (d) True (e) False – it arches over the left main bronchus and left upper lobe bronchus to descend postero-lateral to the left lower lobe bronchus. 9. (a) True – and in the inferior pulmonary ligament. (b) False – the visceral pleura can be seen on a plain radiograph only where it invaginates the lung to form fissures and at the junctional lines. (c) False – the parietal pleura is supplied by the systemic circulation, and the visceral pleura is supplied by the pulmonary and bronchial circulation. (d) False – only two layers of visceral pleura. (e) True – two layers of pleura, extrapleural fat, innermost intercostal muscle and endothoracic fascia. 10. (a) False – incomplete fissures have parenchymal fusion and small bronchovascular structures. (b) False – the oblique fissure separates the upper and middle lobes from the lower lobe on the right.
  18. 18. 8 Module 1: Chest and cardiovascular (c) The lateral and medial portion of the oblique fissure are equidistant from the anterior chest wall. (d) The major fissures appear as a soft tissue linear density from the hilum to the chest wall on standard 10 mm thick CT sections. (e) The minor fissure separates the right middle lobe from the right lower lobe. 11. Regarding the accessory fissures of the lung: (a) The azygos fissure results from failure of normal migration of the azygos vein from the chest wall through the lung. (b) The inferior accessory fissure separates the medial basal segment from the rest of the right lower lobe. (c) The superior accessory fissure lies above the minor fissure. (d) A left minor fissure is seen in 10% of frontal radiographs. (e) The inferior pulmonary ligaments are pleural reflections from the pericardium. 12. Regarding blood supply of the lung: (a) The left bronchial artery arises from the right bronchial artery. (b) The deep bronchial veins may end in the left atrium. (c) The right and left pulmonary arteries are at the same height in the chest. (d) The right upper lobe pulmonary artery is anterior to the right upper lobe bronchus. (e) The veins of the upper lobe are posterior to the arteries and bronchi.
  19. 19. 9 Module 1: Chest and cardiovascular (c) False – the oblique fissures follow a gently curving plane. The upper portion faces forward and laterally and the lower portion forwards and medially. (d) False – the most common appearance is a curvilinear avascular band extending from the hilum to the chest wall, reflecting the lack of vessels in the subcortical zone of the lung. On HRCT, the major fissure appears as a line or a band. (e) False – the minor fissure separates the anterior segment of the right upper lobe from the right middle lobe. 11. (a) True – almost always on the right, rarely an analogous fissure may be seen on the left with the accessory hemiazygos or left superior intercostal vein. (b) True – runs upward and medially towards the hilum, from the medial aspect of the diaphragm. (c) False – superior accessory fissure separates the superior segment of the lower lobe from the basal segments and is inferior to the minor fissure on the frontal radiograph. (d) False – left minor fissure seen in 10% of individuals is hardly seen on frontal or lateral radiographs. It separates the lingular segments from the rest of the upper lobe. (e) False – they are pleural reflections that hang down from the hila and from the mediastinal surface of each lower lobe to the mediastinum and to the medial part of the diaphragm. 12. (a) False – bronchial arteries are variable. Usually the right bronchial artery arises from the third posterior intercostal artery or from the upper left bronchial artery. The left bronchial arteries are two in number and arise from the thoracic aorta. (b) True – the deep bronchial veins communicate freely with the pulmonary veins, end in a pulmonary vein or left atrium. The superficial bronchial veins drain extrapulmonary bronchi, visceral pleura and hilar lymph nodes, end on the right side into the azygos vein and on the left into the left superior intercostal vein or the accessory hemiazygos vein. (c) False – the left pulmonary artery is higher than the left as it arches over the left main bronchus and descends posterior to it. (d) True (e) False – the veins of the upper lobe are anterior to the arteries and bronchi.
  20. 20. 10 Module 1: Chest and cardiovascular 13. In the chest: (a) Air in the oesophagus on axial CT usually indicates a dilated abnormal oesophagus. (b) On T2-W MRI the oesophagus shows similar intensity to skeletal muscle. (c) The thoracic duct transports all of the body lymph into the great veins of the neck. (d) The thoracic duct is mostly a single structure as it runs from the cisterna chyli. (e) The thoracic duct crosses from the left to the right at the level of T4. 14. Regarding the mediastinal blood vessels: (a) The three major aortic branches from right to left are the innominate, left common carotid and left subclavian arteries. (b) In approximately 0.5% of the population the right subclavian artery arises distal to the left subclavian artery. (c) The left brachiocephalic vein is anterior to the subclavian, common carotid arteries and trachea. (d) The internal thoracic veins empty into the corresponding subclavian veins. (e) The left SVC results from a persistent left cardinal vein. 15. Regarding the mediastinal spaces: (a) The pretracheal space is bounded anteriorly by the anterior junctional line. (b) The aortopulmonary window is above the aortic arch. (c) The aortopulmonary window contains the ligamentum arteriosum and the left recurrent laryngeal nerve. (d) The azygo-oesophageal recess lies behind the subcarinal space. (e) The right paratracheal stripe extends down as far as the right tracheobronchial angle.
  21. 21. 11 Module 1: Chest and cardiovascular 13. (a) False – in 80% of normal individuals the oesophagus contains a small amount of air. (b) False – T2-W MRI reveals higher intensity than muscle. The signal intensity on T1-W MRI is similar to that of muscle. (c) False – all but lymph of most of the lung and the right upper quadrant of the body. (d) False – it may consist of up to eight separate channels. (e) False – at T6, it crosses from right to left of the spine and ascends along the lateral aspect of the oesophagus and arches forward across the left subclavian artery and inserts into a large central vein within 1 cm of the junction of the left internal jugular and subclavian veins. 14. (a) True (b) True – the aberrant right subclavian artery runs posterior to the oesophagus from left to right. (c) True – formed by the junction of left internal and subclavian veins. (d) False – into the corresponding brachiocephalic veins. (e) True – in 0.3% to 0.5% of healthy population and in 4.4% to 12.9% of those with congenital heart disease. It usually drains into the coronary sinus, which then communicates with the right atrium. 15. (a) False – anteriorly the SVC or right brachiocephalic veins, ascending aorta with its enveloping superior pericardial sinus and posteriorly the trachea or carina. (b) False – above the pulmonary artery under the aortic arch. (c) True – and fat, though this is not seen on CT due to volume averaging resulting in higher than fat density. (d) True (e) True – air containing trachea and lung are separated by a thin layer of fat on the right, giving rise to the ‘stripe’. This is broadened at the right tracheobronchial angle by the azygous vein which lies between the airway and the lung.
  22. 22. 12 Module 1: Chest and cardiovascular 16. In a chest radiograph: (a) The anterior junctional line is usually straight and extends to the right ventricle. (b) The posterior junctional line is anterior to the oesophagus. (c) The azygo-oesophageal line is below the aortic arch. (d) The right paravertebral stripe is thicker than that on the left due to the azygos vein. (e) On a PA projection, the left superior intercostal vein may project lateral to the aortic arch as a small ‘nipple’. 17. In the chest: (a) The thymus is usually inferior to the left brachiocephalic vein. (b) MRI demonstrates thymic tissue better than CT. (c) The diaphragmatic crus on the right arises from the upper three lumbar vertebrae. (d) The oesophageal hiatus lies posterior to the aortic hiatus. (e) The hiatus for the IVC is posterior to that of the aorta and oesophagus. 18. In the development of the heart: (a) The primitive heart is formed by fusion of two parallel tubes. (b) The heart tube kinks to form a U-shaped loop. (c) The single atrium and ventricle are separated by the dorsal and ventral endocardial cushions. (d) The foramen secundum is a defect in the septum secundum. (e) The foramen ovale is due to two overlapping defects, which act like a valve.
  23. 23. 13 Module 1: Chest and cardiovascular 16. (a) True (b) False – the lungs almost touch each other posterior to the oesophagus to form the posterior junction line. (c) True – the upper few centimetres are usually straight or concave towards the lung. A convex shape suggests a subcarinal mass in adults; however this may be a normal feature in children. (d) False – the left paravertebral stripe is usually wider than the right. (e) True 17. (a) True – and superior to the level of the horizontal portion of the right pulmonary artery. (b) True – after puberty, the density gradually decreases owing to fatty replacement. In older patients the thymus may be indistinguishable from mediastinal fat. On T2-W MRI the signal intensity is similar or sometimes higher than fat and does not change with age. On T1-W MRI, the intensity of normal thymic tissue is similar or slightly higher than that of muscle. (c) True – they arch upward and forward to form the margins of the aortic and oesohageal hiati. (d) False – oesophageal hiatus lies anterior to aortic hiatus. (e) False – the most anterior of the three diaphragmatic hiati is the hiatus for the IVC, which is in the central tendon immediately beneath the right atrium. 18. (a) True – soon this grooves to demarcate the sinus venosus, atrium, ventricle and bulbus cordis from behind forward. (b) True – the caudal end (sinus venosus) receiving venous blood, comes to lie behind the cephalic end (which gives rise to truncus arteriosus). In the fully developed heart, the atria and great vein lie posterior to the ventricles and to the roots of the great arteries. (c) True – these divide the common atrio-ventricular opening into a right (tricuspid) and left (mitral) orifice. (d) False – the foramen secundum is a defect in the septum primum. (e) True – the septum secundum grows to the right of septum primum, is never complete and has a lower free edge. It extends low enough to overlap the foramen secundum and closes it. Ten per cent of individuals have anatomically patent but functionally sealed foramen.
  24. 24. 14 Module 1: Chest and cardiovascular 19. In the heart: (a) The aortic root and pulmonary trunk are covered with parietal pericardium. (b) The right atrium is anterior and to the right of the left atrium. (c) The coronary sinus enters the right atrium on the posterior wall. (d) The crista terminalis demarcates the smooth from the rigid portion of the inner wall of the right atrium. (e) The Eustachian valve directs blood flow from the IVC into the right atrium in the adult. 20. In the heart: (a) The pulmonary valve is anterior and to the right of the aortic root. (b) The interventricular and interatrial septa are in the same plane. (c) The right ventricle contributes to the right cardiac border on the frontal chest radiograph. (d) In the right ventricle the crista supraventricularis demarcates the smooth conus from the trabeculated wall. (e) The moderator band carries the right bundle branch of the conducting system of the right ventricle. 21. Regarding the heart: (a) The left atrial auricular appendage contributes to the normal left cardiac border. (b) The left atrium is posterior to the oesophagus. (c) The four pulmonary veins attach anteriorly in the left atrium. (d) The left atrium lies to the right of the aortic root. (e) The mitral valve is placed in the left lower anterior aspect of the left atrium. 22. In the heart: (a) Most of the external surface of the left ventricle is anterolateral. (b) The mitral valve lies in the same plane as the tricuspid valve. (c) The mitral valve is closely related to the non-coronary and left posterior coronary sinuses.
  25. 25. 15 Module 1: Chest and cardiovascular 19. (a) True (b) True (c) True (d) True (e) False – the Eustachian valve in fetal life serves to direct oxygenated blood from IVC into the foramen ovale. It is rudimentary in adult life. 20. (a) False – anterior and to the left of the aortic root. (b) True – left anterior oblique plane. (c) False – does not usually contribute to the cardiac outline on the frontal chest radiograph. (d) True (e) True – crosses from the lower ventricular septum to the anterior papillary muscle. 21. (a) False – the left atrium does not contribute to the normal cardiac outline. (b) False – is related posteriorly to the oesophagus and left lower lobe bronchus. (c) False – the four pulmonary veins are located at the upper and lower margin of the left atrium postero-laterally. (d) False – it is posterior. (e) True 22. (a) False – though the left ventricle forms most of the left heart border on the frontal radiograph, most of its external portion is postero-lateral. (b) True – right anterior oblique plane. (c) True – it has no septal attachment.
  26. 26. 16 Module 1: Chest and cardiovascular (d) Each anterior and posterior leaflet of the mitral valve is attached to a papillary muscle by chordae tendinae. (e) The sinuses of valsalva are below the valve in the aortic root. 23. Regarding the coronary arteries: (a) Coronary dominance refers to whether the right or left vessels supply the posterior diaphragmatic portion of the interventricular septum and the diaphragmatic surface of the left ventricle. (b) The right coronary artery runs in the atrioventricular groove. (c) The posterior descending artery supplies part of the inferior interventricular septum. (d) The left anterior descending artery runs in the left atrioventricular groove. (e) In approximately 20% of individuals the LAD tapers before reaching the apex. 24. Regarding the coronary veins: (a) The anterior cardiac veins empty into the coronary sinus. (b) The great cardiac vein runs in the anterior interventricular groove. (c) The middle cardiac vein runs in the left interventricular groove. (d) Small cardiac veins run with the marginal branches of the right coronary artery. (e) The left posterior ventricular vein accompanies the posterior descending artery. 25. Regarding the major vessels of the chest: (a) The aortic arch is anterior to the trachea and oesophagus. (b) The left pulmonary artery is attached to the junction of the arch and descending aorta. (c) The left common carotid artery may arise from the brachiocephalic artery. (d) The aortic hiatus is at the level of T12 vertebra. (e) The oesophagus is anteromedial to the descending aorta throughout its course.
  27. 27. 17 Module 1: Chest and cardiovascular (d) True (e) False – the sinuses of valsalva are just above the aortic valve in the aortic root. They are three focal dilatations. The left coronary artery arises from the left posterior sinus, and the right coronary artery arises from the anterior sinus. The right posterior sinus is the non-coronary sinus. 23. (a) True – 85% of people have right dominance. (b) True – ultimately anastomosis with the left circumflex artery in the inferior atrioventricular groove. (c) True (d) False – the left coronary artery gives off the LAD and the left circumflex artery within one centimetre of its origin. The LAD descends in the anterior interventricular groove. (e) True – a large septal branch from the LAD may run parallel to the LAD in this case. 24. (a) False – the anterior cardiac veins drain the anterior surface of the right ventricle and open directly into the right atrium. The venae cordis minimae are minute vessels in the myocardium which also drain into the chambers, mainly the atria. (b) True – and becomes the coronary sinus. (c) False – runs in the posterior interventricular groove. (d) True (e) False – this vein accompanies the obtuse marginal branches of the left coronary artery. 25. (a) True (b) True – the ligamentum arteriosum at the isthmus. (c) True – commonest variant of the major vessels (27%). The left vertebral may arise directly from the arch (2.5%) and lie between the left common carotid and subclavian arteries. (d) True (e) False – in its upper portion the oesophagus lies to the right of the aorta.
  28. 28. 18 Module 1: Chest and cardiovascular 26. The superior vena cava: (a) lies posterior to the right main-stem bronchus. (b) has direct drainage anteriorly from the azygos vein. (c) is formed by the union of the right and left brachiocephalic veins. (d) partly is enclosed in pericardium. (e) has direct drainage from the internal mammary veins. 27. Regarding the pulmonary artery and vein: (a) The right main pulmonary artery is beneath the aortic arch. (b) The right superior pulmonary vein crosses the right main pulmonary artery anteriorly. (c) The left main pulmonary artery is shorter but in a higher position than that on the right. (d) The lower lobe pulmonary veins are vertical as they approach the heart. (e) The pulmonary trunk bifurcates beneath the aortic arch.
  29. 29. 19 Module 1: Chest and cardiovascular 26. (a) False – SVC is anterior to the right main bronchus. (b) False – the azygos drains into the posterior aspect of the SVC. (c) True (d) True (e) False – the internal mammary veins drain into the corresponding brachiocephalic veins. 27. (a) True – and in front of the right main bronchus. (b) True – the hilar point,which is seen on a frontal radiograph. The left is 1 cm higher than that on the right. (c) True (d) False – they run horizontally. (e) True
  30. 30. Limb vasculature and lymphatic system* A. Doss and M. J. Bull 1. In angiography: (a) The femoral artery is punctured at its point of minimal pulsation, to prevent haematoma formation. (b) A low puncture is ideal as it decreases the chances of a retroperitoneal haematoma. (c) The femoral nerve lies lateral to the artery. (d) For interventional procedures of the lower limb a retrograde puncture on the ipsilateral femoral artery is ideal. (e) For punctures of the brachial or axillary arteries, the right arm is usually preferred. 2. In angiography: (a) The Seldinger technique involves passing a catheter through the puncture needle. (b) Retrograde popliteal artery puncture is useful for angioplasty of the superficial femoral artery. (c) Intravenous digital subtraction angiography usually requires less iodinated contrast medium than the intra-arterial technique. (d) Radial artery catheterization is performed using a 5F catheter. (e) Translumbar approach to the aorta is the best way of visualizing the aorta. 3. In the upper chest: (a) The right subclavian artery arises directly from the arch of the aorta. (b) The subclavian artery lies posterior to the subclavian vein. * From Applied Radiological Anatomy: ‘The limb vasculature and the lymphatic system’. 20
  31. 31. Limb vasculature and lymphatic system* ANSWERS 1. (a) False – point of maximal pulsation usually as it passes over the medial third of the femoral head. (b) False – a high puncture placed above the inguinal ligament may result in retroperitoneal haematoma as the artery is difficult to compress without the support of the femoral head. A low puncture may cause a pseudoaneurysm formation or arteriovenous fistula if the profunda femoris is punctured. (c) True – so a large haematoma may compress and damage the nerve. (d) False – an antegrade puncture, so that catheters and wires can be passed down the leg easily. (e) False – the left arm, avoids manipulation of catheters across origin of great vessels. 2. (a) False – a guide wire is passed through the needle into the artery. The needle is removed and a catheter is passed over the guide wire into the artery. (b) True (c) False – requires large amounts. (d) False – 3F catheters usually. (e) False – largely abandoned nowadays, and replaced by the aortogram through the transfemoral approach. 3. (a) False – usually from the brachiocephalic trunk which divides into the right subclavian and right common carotid arteries. The left subclavian arises directly from the arch of the aorta. (b) True – and scalenus anterior muscle and ends at the lateral border of the first rib, where it continues as the axillary artery. * From Applied Radiological Anatomy: ‘The limb vasculature and the lymphatic system’. 21
  32. 32. 22 Module 1: Limb vasculature and lymphatic system (c) The dorsal scapular artery arises from the second part of the subclavian artery. (d) The suprascapular artery arises from the thyro-cervical trunk. (e) The inferior thyroid artery contributes to the blood supply of the spinal cord. 4. Regarding the axillary artery: (a) The subclavian artery continues as the axillary artery at the lateral border of teres major muscle. (b) The pectoralis major muscle divides the axillary artery into three parts. (c) The cords of the brachial plexus are anterior to the second part of the axillary artery. (d) The subscapular artery runs downwards on the posterior axillary wall to the inferior angle of the scapula. (e) The third part is superficial and may be used for arterial puncture. 5. Regarding the arteries of the forearm and hand: (a) The brachial artery divides into radial and ulnar arteries at the level of the neck of the radius. (b) The profunda brachi artery runs in the radial groove. (c) The brachial artery is superficial to the bicipital aponeurosis. (d) The radial artery may branch off higher than the usual level. (e) The radial artery gives off the common interosseus artery 2 cm below its origin. 6. In the lower abdomen and pelvis: (a) There are no terminal branches to the aorta. (b) The common iliac arteries divide at the level of the sacroiliac joints. (c) The common iliac arteries lie in front of the fourth and fifth lumbar vertebrae. (d) The ureters lie anterior to the common iliac arteries. (e) The superior rectal artery lies anterior to the right common iliac artery.
  33. 33. 23 Module 1: Limb vasculature and lymphatic system (c) True – and supplies muscles attached to the medial border of the scapula and takes part in the scapular anastomosis with the third part of the axillary artery. (d) True – and so do inferior thyroid and superficial cervical artery. (e) True – and so does the ascending cervical artery. 4. (a) False – lateral border of first rib to the lower border of teres major muscle is the axillary artery, after which it is the brachial artery. (b) False – pectoralis minor divides it into three parts. (c) False – they surround this artery medially, laterally and posteriorly and separate it from the axillary vein which runs medially and slightly anteriorly. (d) True – and contributes to the scapular anastomosis. (e) True 5. (a) True (b) True – gives branches to scapular and elbow anastomosis. (c) False – superficial throughout its course and overlapped by bicipital aponeurosis at the elbow. (d) True – ‘high take-off’ of radial artery – a common normal variant above the neck of the radius. The deep palmar arch is a continuation of the radial artery. (e) False – ulnar artery. 6. (a) False – three; a pair of common iliac arteries and the median sacral artery anterior and to the left of the body of L4 vertebra. (b) True – into the internal and external iliac arteries. (c) True (d) True – common iliac veins, lumbosacral trunk, obturator nerve, iliolumbar artery and the sympathetic trunk lie posterior to the common iliac trunk. (e) False – anterior to the left common iliac artery.
  34. 34. 24 Module 1: Limb vasculature and lymphatic system 7. In the pelvis and lower abdomen: (a) The superior gluteal artery is a branch of the external iliac artery. (b) The uterine artery is a branch of the anterior division of the internal iliac artery. (c) The umbilical artery is the first branch of the internal iliac artery in the fetus. (d) The internal pudendal artery re-enters the pelvis through the lesser sciatic foramen. (e) The inferior epigastric artery is given off above the inguinal ligament from the external iliac artery. 8. In the lower limb: (a) The main supply to the trochanteric anastomosis is through the superficial femoral artery. (b) The superficial femoral artery passes lateral to and behind the lower shaft of the femur. (c) The popliteal artery lies lateral to the popliteal vein in the popliteal fossa. (d) The descending genicular artery is a branch of the popliteal artery supplying the knee. (e) The anterior tibial artery runs anterior to the interosseous membrane. 9. Regarding the veins of the lower limbs and abdomen: (a) Failure of the right subcardinal vein to connect with the liver leads to absence of the IVC. (b) A persistent left sacrocardinal vein results in a left-sided IVC. (c) The right common iliac vein is crossed by the common iliac artery. (d) The hepatic segment of the IVC is formed from the right vitelline vein. (e) A left-sided IVC drains into the coronary sinus. 10. In the lymphatic system: (a) Lipiodol is retained in lymph nodes for about 12 months. (b) The upper limit of normal in the short axis for retrocrural nodes is 10 mm.
  35. 35. 25 Module 1: Limb vasculature and lymphatic system 7. (a) False – largest branch of the posterior division of the internal iliac artery, passes through greater sciatic foramen. (b) True – runs in the broad ligament. (c) True – persists as the fibrous medial umbilical ligament, which may be recognized in a plain abdominal film in the presence of a pneumoperitoneum. (d) True – supplies the genitalia. (e) True – runs up on the deep surface of the anterior abdominal wall and enters the rectus sheath. 8. (a) False – this anastomosis supplies the femoral head and is formed by anastomosing branches of lateral and medial circumflex femoral and superior gluteal arteries. (b) False – posterior and medial to the femur, through the adductor hiatus. (c) False – this artery lies deep to the popliteal vein. (d) False – this is a branch of the superficial femoral artery, prior to entering the adductor hiatus. The medial and lateral superior and inferior genicular arteries are given off in the popliteal fossa. (e) True – in the lower leg, the artery passes deep to the extensor retinaculum, and can be palpated lateral to the extensor hallucis longus tendon and continues as the dorsalis pedis artery. 9. (a) True – the drainage of the lower body is through the azygos system and SVC. Absent IVC is associated with cardiac abnormalities. (b) True (c) False – this is true with that of the left. (d) True – the other segments are renal and sacrocardinal. (e) False – due to a persistent left sacrocardinal vein, cross-over to the right IVC occurs at the level of the left renal vein. 10. (a) True – used to monitor nodal size following therapy. (b) False – 6 mm, para-aortic and subcarinal nodes may be up to 12 mm.
  36. 36. 26 Module 1: Limb vasculature and lymphatic system (c) Fifty per cent of patients demonstrate cross-drainage of lymphatics from right to left at the level of L3/4. (d) The cisterna chyli continues upwards through the aortic opening in the diaphragm as the thoracic duct. (e) The thoracic duct drains the whole of the chest and limbs.
  37. 37. 27 Module 1: Limb vasculature and lymphatic system (c) True – lumbar gap – non-opacification of nodes at this level on lymphography. (d) True (e) False – the thoracic duct drains all the body below the diaphragm, posterior right chest wall and left of the body above the diaphragm. The right lymph duct drains the remainder.
  38. 38. Module 2
  39. 39. Musculoskeletal and soft tissue (including trauma) A. Doss and M. J. Bull 1. The following are true: (a) The supraspinatus tendon passes above the acromion process. (b) The clavicle has a medullary cavity. (c) The rhomboid fossa marks the site of origin of the costo-clavicular ligament. (d) The clavicle is the last bone to ossify. (e) A distance of less than 5 mm between the humerus and the acromion indicates likely supraspinatus tendon impingement. 2. Regarding the shoulder joint: (a) The capsule of the shoulder joint is lax inferiorly. (b) The long head of the biceps runs under the transverse humeral ligament. (c) The subscapularis bursa is a herniation of the shoulder joint synovial membrane deep to the subscapularis muscle, through a defect in the glenohumeral ligament. (d) Teres major forms part of the rotator cuff. (e) During shoulder arthrography contrast passes normally into the subacromial bursa. 3. Regarding the shoulder joint: (a) CT arthrography is of value in the assessment of the glenoid labrum. (b) T2-W images and STIR (short tau inversion recovery) sequences with fat suppression can identify tears in the supraspinatus tendon. (c) On ultrasound, the supraspinatus tendon is echobright. (d) In anterior dislocation of the shoulder, cortical defects may occur in the anterior aspect of the head of the humerus. 30
  40. 40. Musculoskeletal and soft tissue (including trauma) ANSWERS 1. (a) False – below the acromion. (b) False – there is no medullary cavity because of its mesenchymal origin. (c) True – in 5% of individuals an irregular groove is in the inferomedial aspect of the clavicle from which the costoclavicular ligament arises to insert into the first costal cartilage. (d) False – first bone to ossify, formed in membrane, appears after the first fetal month. (e) True 2. (a) True – attached proximally to the glenoid labrum and distally to the anatomical neck of the humerus. (b) True (c) True (d) False – teres minor, subscapularis, supraspinatus, infraspinatus – prime function of these muscle is to hold the head of the humerus in the glenoid cavity during all movement. (e) False – contrast or air in the subacromial space implies disruption of the supra spinatus tendon. 3. (a) True – the prone oblique position provides more information about the posterior aspect of the glenoid labrum and the capsular attachments, which are important in patients with posterior dislocations. (b) True – the supraspinatus tendon is best seen in the coronal oblique plane. (c) False – the tendinous margin is echobright and central portion is echopoor. (d) False – they occur in the posterior aspect of the head of the humerus (Hill–Sachs lesion), which are best shown by a Striker’s view (patient supine, humerus 90° to the table with a cephald beam at 25°). 31
  41. 41. 32 Module 2: Musculoskeletal and soft tissue (e) All the rotator cuff muscles are attached to the greater tubercle of the humerus. 4. Regarding the upper limb: (a) The radial groove is situated in the radius. (b) The capitulum articulates with the ulna. (c) The ligament of Struthers may compress the median nerve. (d) The capitulum is the first secondary ossification centre to appear in the elbow. (e) A prominent posterior fat pad in a lateral radiograph of the elbow is seen in cases of joint effusion. 5. In the upper limb: (a) The annular ligament of the elbow blends with the ulnar collateral ligament. (b) The bicipital aponeurosis separates the superficial median cubital vein from the deeper brachial artery. (c) The ulna articulates with the carpal bones. (d) The distal radio-ulnar joint has no communication with the carpal joints. (e) The ulna articulates with the triquetral only during ulnar deviation of the wrist. 6. Concerning the wrist and carpus: (a) The mid-carpal joint does not communicate with the radiocarpal joint. (b) On a lateral wrist radiograph the distal radius has a slight volar tilt. (c) The lunate articulates proximally with the radius and distally with the capitate. (d) The flexor retinaculum is attached to the pisiform, hook of hamate, scaphoid tubercle and ridge of the trapezium. (e) Flexor carpi-radialis attaches to the pisiform.
  42. 42. 33 Module 2: Musculoskeletal and soft tissue (e) False – all but the subscapularis, which is attached to the lesser tubercle of the humerus. 4. (a) False – within the radial groove runs the radial nerve and the profunda brachialis artery. This groove is closely applied to the mid shaft of the humerus and a fracture in this location may give rise to neuropraxia. (b) False – capitulum–radial head; trochea – ulna. (c) True – this ligament runs from a supracondylar spur (which may be seen in less than 1% of individuals) to the medial epicondyle with the median nerve and brachial artery beneath it. (d) True – the order in which they appear are as follows: capitulum (1 year), radial head and medial (internal) epicondyle (5 years), trochlea (11 years), olecranon (12 years), lateral (external) epicondyle (13 years) – use the mnemonic CRITOE. (e) True – a prominent anterior fat pad is a normal variant in 15% of individuals. 5. (a) False – it blends with the radial collateral ligament, surrounds the head of the radius like a horseshoe and is attached to the ulna medially. (b) True (c) False – the radius carries the hand.The lower extremity of the radius expands to form the articular surface for the wrist joint and the ulna. (d) True – if a communication is demonstrated at arthrography, the triangular fibrocartilage must be disrupted. (e) False 6. (a) True (b) True – if this is lost, a fracture of the radius should be suspected. (c) True (d) True – this forms the carpal tunnel which contains tendons of flexor pollicis longus, flexor digitorum profundus and superficialis and the median nerve. The tendon of flexor carpiradialis lies in a separate compartment of the carpal tunnel (e) False – flexor carpi-ulnaris.
  43. 43. 34 Module 2: Musculoskeletal and soft tissue 7. In the hand and wrist: (a) In most cases two views are enough to exclude scaphoid fractures. (b) In 15% of cases blood supply is from the distal to the proximal portion of the scaphoid. (c) The scaphoid ossifies in the sixth year. (d) All the metacarpals articulate with each other and with the corresponding carpal bones. (e) The commonest supernumerary bone of the wrist joint is the os radiale. 8. In skeletal imaging: (a) Phased array surface detection coils greatly improve the signal to noise ratio in MRI of bone joint and soft tissue. (b) Abnormalities of cortical bone and calcification are usually not detected by MRI. (c) Meniscal abnormalities of the knee are best demonstrated on T1- weighted scans. (d) A fat fluid level within the suprapatellar bursa of the knee joint indicates a fracture within the joint. (e) Bone scans using 99mTc MDP are very specific for pathology. 9. In the bony pelvis: (a) the triradiate cartilage is seen as a Y-shaped lucency at the acetabulum in an immature skeleton in a plain radiograph. (b) the iliac crest has a separate ossification centre. (c) the rectus femoris originates at the anterior superior iliac spine. (d) the obturator foramen is bounded inferiorly by the sacro-spinous ligaments. (e) the sacrotuberous ligament defines the posterior limit of the lesser sciatic foramen.
  44. 44. 35 Module 2: Musculoskeletal and soft tissue 7. (a) False – four views are necessary, as fractures are easily missed – antero- posterior, 30° antero-posterior, lateral and scaphoid centred view. (b) True – hence fractures at the waist may produce ischaemic necrosis of the proximal portion. (c) True – so do trapezium and trapezoid. Capitate and hamate ossify in the first year, triquetral in the second, lunate in the third, pisiform in the twelfth year. (d) False – all but the first metacarpals which articulate only with the trapezium. (e) True – lies immediately distal to the radial styloid. 8. (a) True (b) True (c) False – T2 Fast spin echo sequence. (d) True – lipohaemarthrosis seen in a lateral radiograph of the knee. (e) False – a three-phase study is used – immediate vascular images (0.3 minutes), a blood-pool phase (3–5 minutes), and delayed static images (4–6 hours). Bone scan is very sensitive to the presence of any pathology, but is relatively non- specific. Hot spots are due to increased blood supply or osteoblast activity and may be seen in infection, fracture or malignancy. 9. (a) True – the ilium, ischium and pubis meet at the triradiate cartilage, fuses at 20 years of age. (b) True – fuses from 20 years onwards. (c) False – Sartorius originates at the anterior Superior ilaic spine and rectus femoris from the anterior inferior iliac spine. It is common for ‘tug’ lesions (avulsion) to develop from the latter in sports related injuries of adolescents. (d) False – the obturator foramen is bounded by the bodies and rami of the pubis and ischium. The sacrospinous ligament defines the inferior limit of the greater sciatic foramen. (e) True – runs from the ischial tuberosity to the side of the sacrum and coccyx and to the posterior inferior iliac spine.
  45. 45. 36 Module 2: Musculoskeletal and soft tissue 10. In the pelvis: (a) The iliopsoas muscle passes anterior to the inguinal ligament. (b) The aponeurosis of the external oblique has a thickening, which runs from the pubic tubercle to the anterior superior iliac spine as the inguinal ligament. (c) The sacroiliac joint does not have a synovial component. (d) The intersosseous sacroiliac ligament is a strong ligament. (e) Each half of the vertebral arch of the sacrum appears at 16–20 weeks of fetal life. 11. Concerning the muscles of the pelvic girdle: (a) The majority of the gluteus maximus merges with the iliotibial tract. (b) The piriformis passes out of the pelvis through the lesser sciatic foramen. (c) The obturator internus arises from the medial part of the obturator membrane and surrounding bone and passes through the lesser sciatic foramen. (d) The gemelli muscles insert into the lesser trochanter. (e) The tendons of obturator internus and gemelli muscles lie between the femoral head anteriorly and gluteus maximus posteriorly. 12. In the pelvis: (a) The anteroposterior view of the plain radiograph is taken with the legs rotated externally. (b) The paraglenoid sulcus transmits the superior branch of the gluteal artery. (c) Shenton’s line runs from the lateral aspect of the femoral neck to the superior border of the obturator foramen on an AP radiograph. (d) The sacrum is better seen with a 35° cephalad angulation on the AP radiograph. (e) The sacroiliac joints are better profiled in the postero-anterior than the anteroposterior projection.
  46. 46. 37 Module 2: Musculoskeletal and soft tissue 10. (a) False – posterior, to insert into the lesser trochanter. (b) True (c) False – has a synovial component. The sacral surface is lined by fibrocartilage and the iliac surface by hyaline cartilage. (d) True – it provides the main strength of the joint. (e) True 11. (a) True (b) False – through the greater sciatic foramen. (c) True (d) False – the gemellus inferior arises from the ischial tuberosity and the gemellus superior arises from the ischial spine and insert into the greater trochanter. (e) True 12. (a) False – rotated internally to compensate for the anteversion of the femoral neck. (b) True (c) False – from the medial aspect of the femoral neck it usually is a smooth curve. (d) True – Ferguson’s view. The Stork’s view to assess instability of the pubic symphysis is taken standing on each leg. Change in alignment of the superior surface of the pubic rami of more than 3 mm is abnormal. (e) True – the plane of the SI joint diverges in the posteroanterior direction and the diverging X-ray beam is nearly parallel in the PA view.
  47. 47. 38 Module 2: Musculoskeletal and soft tissue 13. In pelvimetry: (a) Routine assessment of the female pelvis is performed before delivery. (b) CT or MRI are used in place of plain radiography. (c) The conjugate diameter is the smallest AP diameter between the posterior margin of the symphysis pubis and the anterior aspect of the sacrum. (d) The pelvic outlet dimensions are more important than the inlet dimensions. (e) The transverse outlet diameter is measured between the ischial tuberosities. 14. In the hip joint: (a) The fovea capitis to which the ligamentum teres is attached is not covered in cartilage. (b) The articular cartilage is thickest and broadest superiorly. (c) The fibrous capsule is attached around the rim of the acetabulum and inferiorly to the transverse acetabular ligament. (d) The iliofemoral ligament is a thickening of the posterior capsule. (e) The Von Rosen’s view is useful in the assessment of femoral capital epiphyses in children. 15. Regarding the femur: (a) MRI has a high sensitivity and specificity in detecting avascular necrosis of the femoral head. (b) The anteversion of the neck of the femur increases from childhood into adult life. (c) The principal blood supply to the head of the adult femur is from the medial and lateral circumflex femoral arteries. (d) The nutrient artery of the femur travels cranially. (e) The medial condyle is smaller than the lateral condyle.
  48. 48. 39 Module 2: Musculoskeletal and soft tissue 13. (a) False (b) True (c) True – the most important measurement. Normal range is 11–12.5 cm.Less than 10.5 cm indicates increasing likelihood of cephalopelvic disproportion. (d) False – there is a considerable increase in the outlet diameter of up to 4 cm during delivery due to relaxation of the symphysis pubis and rotation of the sacroiliac joints. (e) True – average is 10.5 cm. 14. (a) True (b) True (c) True – where the weight is borne. (d) False – this is the ischio-femoral ligament. The ilio-femoral ligament is attached to the anterior inferior iliac spine and to the inter-rochanteric line, and is anterior to the femoral neck. (e) False – the Frog’s lateral view is used for this – the Von Rosen’s view is used in the assessment of congenital dislocation of the hip. Judet’s views of the acetabulum and femoral head give information on the anterior and posterior columns of the acetabulum. 15. (a) True (b) False – in children the anteversion is greater, 50° at 1 year, 25° at 3–5 years and 8° by adulthood. (c) True – the central part of the head may be supplied by the artery of ligamentum teres, a branch of the obturator artery. This may be absent in about 20% of individuals. Intracapsular fractures of the femoral neck can compromise the blood supply to the head of the femur as the circumflex arteries may be torn. This gives rise to a high incidence of avascular necrosis of the femoral head or non-union. (d) True – ‘Flee from the knee’. On a lateral view this is not to be mistaken for a fracture. (e) False – larger. Hence the inferior surface of the femur is nearly horizontal despite the shaft being oblique.
  49. 49. 40 Module 2: Musculoskeletal and soft tissue 16. In the lower limb: (a) The patella is a sesamoid bone within the quadriceps tendon. (b) The fabella is frequently found in the lateral head of gastrocnemius. (c) The shaft of the femur ossifies at the 35th week of fetal life. (d) In a bipartite patella the supero-lateral part is separate to the rest of the patella. (e) Tensor fascia lata arises from the anterior superior iliac spine and inserts into the lateral condyle of the femur. 17. In the lower limb: (a) The rectus femoris arises from the anterior superior iliac spine. (b) Gracilis, sartorius and semitendinosus insert into the medial condyle of the tibia. (c) The adductor magnus inserts along the linea aspera, the medial supracondylar line and the adductor tubercle of the medial femoral condyle. (d) The adductor hiatus interrupts the distal attachment of the adductor longus muscle. (e) The biceps femoris attaches to the lateral condyle of the femur. 18. In the knee joint: (a) The synovium lining the joint is extracapsular. (b) A Baker’s cyst is an inflamed or swollen medial gastrocnemius – semimembranosus bursa. (c) The lateral collateral ligament is separated from the capsule by the popliteus tendon. (d) The anterior cruciate ligament passes from the anterior intercondylar area of the tibia to the medial femoral condyle. (e) The medial collateral ligament is a flattened band that blends posteriorly with the fibrous capsule.
  50. 50. 41 Module 2: Musculoskeletal and soft tissue 16. (a) True – largest sesamoid bone. (b) True – a fabeLLa –‘L’ for lateral. (c) False – starts to ossify at the seventh week of fetal life. (d) True – usually bilateral. May be difficult to differentiate from a fracture. (e) False – inserts into the iliotibial tract – a strong thickened band of deep fascia of the lateral aspect of the thigh (fascia lata) which is attached to the lateral condyle of the tibia. 17. (a) False – from the anterior inferior iliac spine. The sartorius and tensor fascia lata arise from the anterior superior iliac spine. The rectus femoris inserts into the base of the patella and by the patellar ligament to the tibial tuberosity. This insertion is the same for the other muscles which form the quadriceps femoris; vastus – lateralis, medialis and intermedius. (b) True (c) True (d) False – the femoral vessels pass through the hiatus in the adductor magnus to become the popliteal vessels. (e) False – originates from the ischial tuberosity (long head) and the linea aspera (short head) and inserts into the head of the fibula. 18. (a) False – intracapsular. (b) True – best seen on ultrasound as an anechoic area that may connect to the knee joint. (c) True – it is a cord-like structure between the lateral epicondyle of the femur and head of the fibula. (d) False – to the medial surface of lateral femoral condyle. It prevents femur moving backwards on tibia. (e) True
  51. 51. 42 Module 2: Musculoskeletal and soft tissue 19. In the knee joint: (a) The anterior cruciate ligament has low signal intensity on T1- and T2- weighted sagittal scans. (b) The posterior cruciate ligament (PCL) arises from the posterior intercondylar area and inserts into the anterior part of the lateral surface of the medial femoral condyle. (c) The medial meniscus is larger and more semicircular than the lateral meniscus. (d) Discoid menisci are less likely to tear than normal menisci. (e) The posterior horn of the lateral meniscus is attached to medial condyle of the femur by the menisco-femoral ligament, which divides to pass either side of the anterior cruciate ligament. 20. In the knee: (a) A tunnel view shows the patella well. (b) The medial femoral condyle projects more anteriorly compared to the lateral femoral condyle. (c) A fat fluid level in the suprapatellar bursa in a horizontal beam lateral radiograph indicates a fracture within the joint. (d) The sartorius and gracilis tendons are posteromedial to the joint. (e) The popliteal vein lies deep to the popliteal artery. 21. Regarding the lower legs: (a) The muscles of the anterior compartment are more prone to be affected by compartmental syndrome.
  52. 52. 43 Module 2: Musculoskeletal and soft tissue 19. (a) True – partial tear may manifest as high signal within the ligament on T2 or T2* images. More often a torn ACL is not visualized. Coronal images show medial and lateral collateral ligaments, sagittal images show menisci, cruciate ligaments and articular cartilages. Normal menisci and ligaments are low signal on T1 and T2. (b) True – the PCL is shorter and stronger than the ACL. It is infrequently torn compared with ACL. (c) True – the outer margin of the medial meniscus is blended with the fibrous capsule and the deep surface of the medial collateral ligament. (d) False – discoid menisci are thicker. However, more prone to tear and may be symptomatic even if not torn. (e) False – pass either side of PCL. The anterior part is called ligament of Humphrey and the posterior part, ligament of Wrisberg. One or the other can be seen in about 70% of cases. They can be mistaken for a tear of the posterior horn of the lateral meniscus or for loose bodies in front of or behind the PCL. 20. (a) False – a skyline view of the patella shows it best. A tunnel view of the intercondylar fossa of the upper end of the tibia is used to detect intra-articular opacities. These opacities are ‘loose’ bodies if they change position. (b) False – the lateral femoral condyle projects more anteriorly and tends to prevent lateral dislocation. (c) True – has a high correlation with a tibial plateau fracture – probably the most commonly missed fracture of the knee. (d) True (e) False – the vein is superficial to the artery. Hence during Doppler ultrasound for venous thrombosis, excess pressure with the probe will obliterate the lumen and it cannot be visualized. This applies to ultrasound of veins in general. However, this is a sign to be elicited with the probe held transverse to the vein, to ensure patency of veins. 21. (a) True – they are in a compartment enclosed by the tibia, fibula and the interosseus membrane.
  53. 53. 44 Module 2: Musculoskeletal and soft tissue (b) The Achilles tendon has a sheath. (c) The tibialis anterior is the most medial and the largest of the flexor tendons of the foot. (d) The flexor digitorum longus tendon is lateral to flexor hallucis longus at the level of the talus. (e) The tibialis posterior inserts into the talus. 22. In the ankle and the foot: (a) The deltoid ligament lies medially, deep to the flexor tendons. (b) The deltoid ligament is responsible for about 85% of all ankle ligament injuries. (c) The tibiofibular and calcaneofibular ligaments form the superior group of the lateral collateral ligament complex in the ankle. (d) The sinus tarsus is a space between the talus and calcaneus and is filled with fat and hindfoot ligaments. (e) Tarsal coalition is usually of no consequence. 23. Concerning imaging of the ankle and foot: (a) Boehler’s angle is usually about 28°. (b) Congenital tarsal coalitions are best visualized using oblique radiographs with the foot internally rotated. (c) On ultrasound, tendons are echopoor. (d) In the AP view of the foot the medial margin of the base of the second metatarsal should be in line with the medial margin of the intermediate cuneiform. (e) A fracture through the base of the fifth metatarsal is usually longitudinal to the long axis of the metatarsal.
  54. 54. 45 Module 2: Musculoskeletal and soft tissue (b) False – strongest tendon, but no sheath, therefore tenosynovitis does not accur. (c) False – this is the tibialis posterior which provides support to the longitudinal arch. Problems in the arch can lead to tendonitis or even rupture usually just at or above the tibiotalar joint. (d) False – the mnemonic Tom (tibialis posterior), Dick (flexor digitorum longus), and (posterior tibial vessels and nerve), Harry (flexor hallucis longus) is helpful in remembering the relations of these important structures at the level of the ankle joint from medial to the poserto-lateral aspect. (e) False – talus has no muscle attachment. The tibialis posterior inserts into the navicular, and gives variable slips to tarsal bodies and bases of second, third and fourth metatarsals. 22. (a) True (b) False – the lateral collateral ligament complex is responsible for about 80% of all ankle ligament injuries. (c) False – these form the inferior group. The superior group is formed by the anterior and posterior tibial and fibular ligaments. The anterior talofibular ligament is the most commonly torn ligament in the ankle. (d) True – in the sinus tarsi syndrome this fat is obliterated with disruption of the ligaments. (e) False – this is a common cause of a painful flat foot. The coalition which may be bony, cartilagenous or fibrous, most commonly occurs at the calcaneo- navicular joint and is usually bilateral. 23. (a) True – an angle less than 20° indicates flattening of the calcaneum due to crush injuries resulting from jumping on to a hard surface from a height. (b) False – CT, particularly in the coronal plane, is the best way of looking at the subtalar joint. (c) False – tendons are echobright. Echopoor areas in the tendon may be due to tendonitis and a gap in the tendon is diagnostic of a tear. (d) True – in the oblique view of the foot, the medial margin of the base of the third metatarsal should be in line with the medial margin of the lateral cuneiform. If not, it is a Lisfranc injury. (e) False – avulsion fracture of the base of the fifth metatarsal is transverse to the long axis of the metatarsal. An apophysis which mimics a fracture is longitudinal to the long axis of the metatarsal.
  55. 55. Module 3
  56. 56. Gastro-intestinal (including hepatobiliary) A. Doss and M. J. Bull 1. Regarding the abdomen: (a) By the fifth week of fetal life the gut tube within the peritoneal cavity is suspended by the dorsal mesentery. (b) The blind ending hind gut is closed by the cloacal membrane. (c) The superior mesenteric artery supplies the gut from the inferior half of the duodenum to the splenic flexure. (d) The coeliac axis supplies the gut from the upper oeosphagus to the superior half of the duodenum. (e) The inferior mesenteric artery supplies the hind gut distal to the hepatic flexure up to the anal canal. 2. During embryological development: (a) A condensation of endoderm in the dorsal mesogastrium forms the spleen. (b) In the third week of fetal life the liver arises from a hepatic diverticulum which buds from the duodenum. (c) The dorsal pancreatic bud arises from the hepatic diverticulum. (d) The pancreas may form a complete ring around the duodenum. (e) The ventral pancreatic duct forms the accessory pancreatic duct. 3. In the development of the gut: (a) The cranial limb of the primary intestinal loop gives rise to most of the ileum. (b) During the sixth week of fetal life the midgut herniates into the umbilical cord. 48
  57. 57. Gastro-intestinal (including hepatobiliary) ANSWERS 1. (a) True (b) True (c) True (d) False – from the lower oesophagus. (e) False – distal to the splenic flexure up to the upper half of the anal canal. 2. (a) False – the spleen develops as a condensation of mesenchyme in the dorsal mesogastrium of the lesser sac during the fifth week. It is derived from mesoderm and not from gut endoderm. (b) True – the gall bladder and cystic duct develop from a further budding from the hepatic diverticulum. (c) False – the dorsal bud develops from the duodenum opposite the hepatic diverticulum from which sprouts the ventral diverticulum. The dorsal bud gives rise to the head, body and tail of the pancreas. The ventral bud develops into the uncinate process. (d) True – annular pancreas probably results from a bilobed ventral bud with the two lobes migrating in opposite directions, around the duodenum to fuse with the dorsal bud. (e) False – the ventral pancreatic duct becomes the main pancreatic duct of Wirsung. The dorsal pancreatic duct forms the accessory duct of Santorini. 3. (a) True – the caudal limb develops into the ascending and transverse colon. (b) True – as it herniates into the umbilicus the primary intestinal loop rotates around the axis of the superior mesenteric vessels through 90° in an anti- clockwise direction. 49
  58. 58. 50 Module 3: Gastro-intestinal (c) During the 24th week of fetal life the midgut retracts into the abdomen. (d) The mesenteries of the ascending and descending colon blend with the posterior peritoneal wall. (e) The lower part of the anal canal is ectodermal in origin. 4. In developmental anomalies of the gut: (a) Failure of recanalization of the lumen of the midgut may result in atresia or stenosis of the bowel. (b) Meckel’s diverticulum represents the remains of the embryonic right umbilical vein. (c) In an undescended caecum, neonatal intestinal obstruction is caused by Ladd’s band. (d) Ischaemic changes to the bowel in the fetal umbilical hernia may result in atresia or stenosis of the bowel. (e) The embryonic vitello intestinal duct gives rise to the appendix. 5. Regarding the peritoneum: (a) It is a closed sac in both male and female. (b) The greater and lesser sac communicate through the epiploic foramen. (c) The flow of peritoneal fluid is directed in a cephalad direction by the negative intra-abdominal pressure generated in the upper abdomen by respiration. (d) The peritoneal cavity is divided by the greater omentum into the supramesocolic and inframesocolic compartments. (e) The root of the transverse mesocolon extends from the infra-ampullary segment of the duodenum through the head and along the lower edge of the body and tail of the pancreas. 6. Concerning the peritoneal spaces: (a) The right subphrenic space extends from the right coronary ligament postero-inferiorly to the falciform ligament medially. (b) In the supine position the hepatorenal space (Morrison’s pouch) is more dependant than the right paracolic gutter. (c) The lesser sac is posterior to the pancreas. (d) Fluid collections in the pelvis that spread to the left subphrenic space, generally involve the lesser sac.
  59. 59. 51 Module 3: Gastro-intestinal (c) False – in the tenth week it rotates counter-clockwise through 180° and the cephalic limb returns first, passing upwards into the space in the left of the abdomen. (d) True – this forms an avascular plane, which the surgeon employs to mobilize the right and left colon. (e) True – an ectodermal invagination termed proctodeum. The pectinate line in the adult marks the junction of the ectoderm and endoderm in the anal canal. 4. (a) True – in the sixth week of fetal life, proliferation of the endodermal lining of the gut completely occludes its lumen. Recanalization takes place and is completed by the ninth week. Incomplete recanalization may lead to gut duplication. (b) False (c) True – the peritoneal fold which normally seals the caecum in the right iliac fossa passes across the duodenum (Ladd ‘s band) and causes a neonatal intestinal obstruction. The small bowel mesentery in this case is a narrow pedicle and allows volvulus of the whole small intestine – volvulus neonatorum. (d) True (e) False – it may persist as Meckel’s diverticulum. 5. (a) False – closed in the male, penetrated by the fallopian tubes in the female. (b) True – foramen of Winslow. (c) True – and is directed by gravity. (d) False – the transverse mesocolon and transverse colon divide the peritoneal cavity. (e) True 6. (a) True – the falci form ligament separates it from the left subphrenic space. (b) True – hence a common site for collections. (c) False – anterior to pancreas, behind and to the left of the stomach. (d) False – the splenorenal and gastrosplenic ligaments limit the lesser sac on the left. Therefore fluid collection spreading into the left subphrenic space does not involve the lesser sac.
  60. 60. 52 Module 3: Gastro-intestinal (e) Subphrenic collections are more common on the left than the right. 7. Concerning the peritoneal spaces: (a) The right inframesocolic space is in direct communication with the pelvis. (b) The paracolic gutters are retroperitoneal recesses on the posterior abdominal wall lateral to the ascending and descending colon. (c) There are two potential spaces posterior to the bladder in women. (d) In the supine position the Pouch of Douglas is the most dependent portion of the peritoneum. (e) The peritoneum is reflected on the prostate. 8. In the pelvic peritoneum: (a) The rectum is covered by peritoneum on the front up to the junction of the middle and lower thirds. (b) The peritoneum is reflected on the infero-lateral aspect of the bladder bilaterally. (c) The broad ligaments contain the fallopian tubes. (d) The left limb of the sigmoid mesocolon is attached medially to the left psoas muscle. (e) The left ureter runs in the apex of the sigmoid mesocolon. 9. In the abdomen: (a) The superior mesenteric vessels lie in the small bowel mesentery. (b) The root of the transverse mesocolon is confluent with the root of the small bowel mesentery. (c) The greater omentum inserts into the antero-superior aspect of the transverse colon.
  61. 61. 53 Module 3: Gastro-intestinal (e) False – the phrenicocolic ligament extends from the splenic flexure of the colon to the diaphragm, partially separates the left posterior subphrenic space from the rest of the peritoneal cavity. It forms a partial barrier to the spread of fluid from the left paracolic gutter into the left subphrenic space which is why right- sided collections are more common than left-sided collections. 7. (a) False – the inframesocolic compartment is divided into the smaller right and larger left spaces by the root of the small bowel mesentery which runs from the duodenojejunal flexure to the ileocaecal valve. The right inframesocolic compartment is bounded by the transverse colon and the root of the small bowel mesentery. The left inframesocolic space is in free communication with the pelvis on the right of the midline and the mesentery of the sigmoid colon forms a partial barrier on the left of the midline. (b) False – these are peritoneal recesses. Both are in continuity with the pelvic peritoneal spaces. (c) True – the rectouterine pouch of Douglas and the utero-vesical pouch. Men have one potential space posterior to the bladder – the recto-vesical pouch. (d) True (e) False 8. (a) True (b) False – it is reflected over the fundus of the bladder. (c) True – the layers of peritoneum on the anterior and posterior surfaces of the uterus are reflected laterally as the broad ligaments. (d) True (e) False – the sigmoid and superior rectal vessels run between the layers of the sigmoid mesocolon and the left ureter runs behind its apex into the pelvis. 9. (a) True – in front of the horizontal part of the duodenum. (b) True – near the uncinate process of the pancreas. The middle colic vessels course through the transverse mesocolon. (c) True – the greater omentum descends from the greater curve of the stomach and proximal duodenum, passes inferiorly and then turns superiorly to insert into the transverse colon.
  62. 62. 54 Module 3: Gastro-intestinal (d) The lesser omentum forms the anterior surface of the lesser sac. (e) The inferior extent of the lesser omentum attaches to the porta hepatis. 10. Regarding the peritoneal ligaments: (a) Between the two layers of the right coronary ligament is the bare area of the liver. (b) The gastro-splenic ligament is a continuation of the lesser omentum from the stomach to the spleen. (c) The falciform ligament contains the ligamentum venosum in its free edge. (d) The phrenicocolic ligament is continuous with the splenorenal ligament. (e) The hepatoduodenal ligament transports the portal triad. 11. In the anterior abdomen: (a) The superficial fascia has a superficial layer that is continuous with the superficial perineal fascia. (b) The paired rectus abdomini are separated by the linea alba. (c) The rectus sheath is formed by the rectus muscles. (d) The inguinal ligament is formed by the aponeurosis of the internal oblique muscle. (e) The superior epigastric artery runs in the posterior rectus sheath. 12. In the abdomen: (a) The foregut extends from the lower oesophagus to the second part of the duodenum. (b) The outline of both psoas muscles is seen in the majority of plain radiographs.
  63. 63. 55 Module 3: Gastro-intestinal (d) True – its free edge extends to the porta hepatis as the hepatoduodenal ligament. (e) False – the superior extent of the lesser omentum is attached to the fissures for the porta hepatis and ligamentum venosum. 10. (a) True – the liver in the bare area is attached to the diaphragm by areolar tissue and this area is continuous with the anterior pararenal space. (b) False – this is a continuation of the greater omentum from the greater curve of the stomach to the spleen. It contains the short gastric and left gastroepiploic vessels. (c) False – this carries the obliterated left umbilical vein (ligamentum teres) in its free edge. It is continuous with the fissure for the ligamentum venosum. (d) True – and the transverse mesocolon (see question 6 (e)). (e) True – this represents the thickened right edge of the lesser omentum. Behind it is the epiploic foramen leading into the lesser sac. 11. (a) False – the deep layer of the superficial fascia passes inferomedially to form the superficial perineal fascia. (b) True (c) False – the aponeurosis of the oblique and transverse muscles of the anterior abdominal wall form the rectus sheath within which the rectus abdominis muscle is enclosed. (d) False – the aponeurosis of the external oblique muscle forms a strong thick band – the inguinal ligament between the anterior superior iliac spine and the pubic tubercle. (e) True – this is a branch of the internal thoracic (mammary artery), runs behind the rectus muscle and then pierces and supplies it. Inferiorly it anastomoses with the inferior epigastric artery, a branch of the external iliac artery. 12. (a) False – the foregut extends from the pharynx to the second part of the duodenum. (b) False – only seen in 48% of normal radiographs.
  64. 64. 56 Module 3: Gastro-intestinal (c) In a plain radiograph the properitoneal fat lines seen in each flank represent the borders of the peritoneum. (d) The cardiac orifice of the stomach is at the level of T10 vertebra. (e) The right and left vagus nerves, oesophageal branches of the left gastric vessels are transmitted through the oesophageal hiatus in the diaphragm. 13. The oesophagus: (a) has both striated and smooth muscle fibres in its lower third. (b) is related to the left recurrent laryngeal nerve. (c) is anterior to the right subclavian artery in the thorax. (d) is related to the azygos vein and the pleura below T4. (e) is posterior to the left main bronchus. 14. Regarding the oesophagus: (a) The upper third is supplied by the inferior thyroid artery. (b) The middle third is supplied by the branches of the aorta. (c) The left gastric artery supplies the lower third. (d) The lower third drains into the portal system. (e) The upper oesophagus has lymphatic drainage to the mediastinal lymph nodes. 15. Regarding the gullet: (a) Deglutition is best assessed by barium swallow examination using spot films. (b) A high kV chest radiograph may show the right wall of the oesophagus better than low kV chest radiograph.
  65. 65. 57 Module 3: Gastro-intestinal (c) True (d) True (e) True 13. (a) False – the muscular layers of the oesophagus are the superficial longitudinal and inner circular layers. In the upper third the fibres are striated, in the middle third the muscles are both striated and smooth fibres and in the lower third there are only smooth muscle fibres. (b) True – in the neck the left recurrent laryngeal nerve runs in the tracheo- oesophageal groove and the trachea is anterior to the oesophagus. (c) False – though the oesophagus enters the thorax in the midline it deviates to the left of the midline. In the upper thorax, the left subclavian artery, aortic arch and upper part of descending aorta lie on its left. (d) True – above T4 the oesophagus lies next to the pleura – forming the pleuro- oesophageal line. (e) True – in the thorax from above downwards the trachea, left main bronchus, right pulmonary artery, left atrium and pericardium. 14. (a) True – a branch of the subclavian artery. (b) True (c) True (d) True – the left gastric vein drains the lower third into the portal system. The middle third drains into the azygos, therefore there is an important anastomosis between the azygos and portal system via the left gastric vein. The upper third drains into the brachiocephalic veins. (e) False – the upper oesophagus has lymphatic drainage into the deep cervical nodes, the middle to the posterior mediastinal nodes of the coeliac group. 15. (a) False – videofluoroscopy is used to assess the act of deglutition and provides anatomical information. (b) True – this may demonstrate the right wall of the oesophagus and azygos vein as they are outlined by the lung – the azygo-oesophageal line.
  66. 66. 58 Module 3: Gastro-intestinal (c) An oesophageal stricture is best assessed with the patient upright. (d) The normal indentations of the oesophagus are seen anteriorly and to the left. (e) The aberrant right subclavian artery with a left-sided arch of the aorta causes a posterior indentation of the oesophagus. 16. The stomach: (a) is completely covered by peritoneum. (b) is anterior to the left kidney. (c) has a blood supply from all three branches of the coeliac axis. (d) has a lymph drainage that follows the arterial supply. (e) has areae gastricae which are longitudinal elevations of the mucosa. 17. Concerning the stomach: (a) Ultrasound of the stomach is useful in the diagnosis of infantile pyloric stenosis. (b) 111In DTPA can be used to assess gastric emptying. (c) The local spread of stomach tumours is best assessed by MRI. (d) The anterior surface of the stomach can be differentiated from the posterior surface during a barium meal. (e) The oesophagogastric junction is the ‘B’ ring or Schatzki ring.
  67. 67. 59 Module 3: Gastro-intestinal (c) False – in the prone position the oesophagus is distended well and strictures which may be missed in the upright position are best seen. (d) True – from above downwards these are as follows; where the pharynx joins the oesophagus, aortic arch, left main bronchus and where the oesophagus passes through the diaphragm. (e) True – in a left-sided aortic arch the aberrant right subclavian artery is the last brachiocephalic branch and courses obliquely from the left to the right behind the oesophagus. The aberrant left main pulmonary artery produces an anterior indentation. 16. (a) True – the lesser and greater omentum. (b) True – and the left suprarenal gland, gastric surfaces of spleen and anterosuperior surface of the pancreas, the mesocolon and the transverse colon. (c) True – the left gastric (from coeliac trunk) , right gastric (a branch of the common hepatic artery which arises from the coeliac artery), short gastric and left gastroepiploic arteries from the splenic artery (a branch of the coeliac trunk), right gastroepiploic artery from the gastroduodenal artery (a branch of the hepatic artery). (d) True – and drains into the coeliac lymph nodes. (e) False – these are small nodular elevations of the mucosal surface which measure 2–3 mm seen particularly in the gastric antrum. 17. (a) True – as well as appendicitis, and intussusception in children. (b) True (c) True – endoluminal ultrasound is probably best to assess the stomach wall. (d) True – in the supine position, barium pools around the posterior rugal folds due to gravity. (e) False – the lower end of the oesophagus is dilated to form the vestibule, just above the oesophagogastric junction (mucosal junction between the oeosphagus and stomach – the ‘Z’ line). The upper limit of the vestibule is the ‘A’ ring and the lower limit as the ‘B’ ring or Schatzki ring which is usually below the diaphragm.
  68. 68. 60 Module 3: Gastro-intestinal 18. Regarding the duodenum: (a) This C-shaped tube is wholly retroperitoneal. (b) The first part runs upwards, forwards and to the right. (c) The duodenal cap has the same rugal pattern as the pylorus. (d) The IVC lies directly behind the first part of the duodenum. (e) The head of the pancreas is inferior to the first part of the duodenum. 19. Regarding the duodenum: (a) The second part is anterior to the hilum of the right kidney. (b) The ampulla of Vater is in the posteromedial aspect of the second part. (c) The fundus of the gall bladder lies anterior to the second part. (d) The superior mesenteric vessels are posterior to the third part. (e) The left psoas muscle is posterior to the terminal portion of the third part. 20. Regarding the duodenum: (a) The duodenojejunal junction is at the level of the second lumbar vertebra. (b) The duodenal junction is held by the ligament of Treitz, a peritoneal fold that ascends to the left crus of the diaphragm. (c) The mucosa of the first part of the duodenum is broken up into circular folds – ‘plica circularis’. (d) The duodenal lymphatic drainage is primarily to the coeliac nodes. (e) The duodenum is predominantly supplied by the coeliac axis.
  69. 69. 61 Module 3: Gastro-intestinal 18. (a) False – the first inch (2.5 cm) of the duodenum is intraperitoneal. The remainder is retroperitoneal as it is covered only anteriorly by peritoneum. (b) False – it runs upwards, backwards and to the right from the pylorus. Hence, the right anterior oblique position is needed to open out the loop formed by the first part with the second part of the duodenum. (The patient ’s right side is half-way off the table with an overcouch tube.) (c) True – this is the first 2 cm of the duodenum which is slightly conical in shape and is between the folds of the greater and lesser omentum. (d) False – the portal vein lies between the first part of the duodenum and the IVC posteriorly. (e) True 19. (a) True (b) True (c) True – and right lobe of liver. (d) False – exit the neck of the pancreas and run over the third part. (e) False – the right ureter, right psoas, IVC and aorta are the posterior relations of the third part of the duodenum from the right to left. The fourth part lies on the left psoas muscle. 20. (a) True (b) False – it ascends to the right crus of the diaphragm. An abnormal position of this ligament indicates mal-rotation. (c) False – the mucosa of the first part of the duodenum is smooth. The rest of the small bowel is broken into the ‘plica circularis’. (d) False – the proximal duodenum is drained via pancreatico-duodenal nodes to the gastroduodenal nodes and to the coeliac nodes. The distal duodenum drains to the pancreatico-duodenal nodes which drain into the superior mesenteric nodes. (e) False – dual supply from SMA and coeliac axis – hence the difficulty in controlling bleeding from an eroding duodenal ulcer.
  70. 70. 62 Module 3: Gastro-intestinal 21. In the small intestine: (a) The transition from jejunum to the ileum takes place gradually. (b) A Meckel’s diverticulum occurs in 2% of the population. (c) The small bowel mesentery is anterior to the right gonadal vessels. (d) The plica circulares are most prominent in the terminal ileum. 99m (e) Technetium-labelled colloid is used to detect Meckel’s diverticulum. 22. Regarding the large intestine: (a) The lateral cutaneous nerve of the thigh is posterior to the caecum. (b) An appendicolith is seen in 15% of the normal population. (c) The ascending and descending colon are covered anteriorly and laterally by peritoneum. (d) The third part of the duodenum lies posteriorly to the transverse colon. (e) The proximal third of the transverse colon is supplied by the middle colic artery and the remaining two-thirds by the left colic artery. 23. Regarding the large intestine: (a) The sigmoid colon is retroperitoneal. (b) The marginal artery of Drummond is a single arterial trunk formed by anastomoses of arteries around the inner border of the colon. (c) Taenia coli are thickenings of the longitudinal muscle layers. (d) The colon has sacculations due to the mucosal folds. (e) The appendices epiploicae are sparse in the sigmoid colon.
  71. 71. 63 Module 3: Gastro-intestinal 21. (a) True (b) True – it is found in the ileum, on the antimesenteric border. Its blind end may contain gastric mucosa, liver or pancreatic tissue. (c) True – from left to right posteriorly are the fourth part of duodenum, aorta, IVC, right gonadal vessels, the right ureter and psoas muscle. (d) False – they become less prominent and less numerous in the ileum until at the terminal ileum, they are almost entirely absent. (e) False – Meckel’s diverticulum containing gastric mucosa is detected using 99m Technetium pertechnetate. Occult bleeding in the small bowel is detected using 99mTc labelled with colloid or red cells. Active bleeding at a rate of more than 0.5 ml per minute is required to enable detection at angiography. 22. (a) True – and the femoral nerve, the psoas and iliacus muscles. (b) True – in patients with acute abdominal pain their presence indicates a 90% chance of appendicitis. (c) True – this binds it to the posterior abdominal wall. (d) False – it is the second part of the duodenum. (e) False – the proximal two-thirds is supplied by the middle colic artery (branch of the superior mesenteric artery). The distal one-third is supplied by the ascending branch of the left colic artery (from the inferior mesenteric artery). 23. (a) False – the sigmoid colon is completely invested in peritoneum. It is attached to the posterior pelvic wall by the fan-shaped sigmoid meso-colon. (b) True (c) True – these are three narrow bands present on the outer wall of the colon, they converge on the appendix proximally and the rectum distally. (d) False – the taeniae are shorter than the colon. Therefore the colon is thrown into sacculations which give the appearance of haustra on radiographs. (e) False – they are sparse in the caecum and rectum and most numerous in the sigmoid colon. Herniation of mucous membrane through the appendices apiplocae leads to formation of diverticula.

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